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Leveraging EHR for Opioid Stewardship
Session BP1, February 11, 2019
Todd Burstain, MD CMIO Ochsner Health Systems
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Todd Burstain, MD
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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• Opioid Epidemic Review
• Analytic Reporting
• Standardized Prescribing
• Opioid Risk Tool
• Morphine Equivalent Daily Dose
• Registries for Chronic Users
• Health Maintenance Build
• PMP Link
• Pain Management Innovations
• Outcomes
Agenda
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• Outline analytic tools and role in changing prescribing behavior
• Discuss role of Opioid Risk Tool in opioid stewardship
• Outline basis for Opioid Registry development
• Discuss how Health Maintenance tools can leverage stewardship
• Outline how EHR can link to PMP data
Learning Objectives
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The Start of an Epidemic
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The Opioid Crisis – Nationally and Locally
• 63,632 Americans died in 2016 from Drug Overdose
• 66% from prescription/illicit opioids
• Prescription opioid overdose death rate up 10.6% (2015-6)
• 21-29% of patients given opioids for chronic pain end up
misusing them
• 80% of patients abusing Heroin began with abusing
prescription opioids
• 2003 to 2013 Neonatal Abstinence Syndrome in La increased
by 380%
• Economic cost to US over $78 billion/year
• Deaths from overdose > homicide in Orleans Parish 2016
• 6
th
highest rx/pt in US in LA at 1.02 rx/person in state
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Overall Strategy
• Build Governance Structure
• Educate Providers and Patients
– Why is it important
– What is best practice
• Provide analytic feedback data
– Target Key areas
• Build Best Practice into Epic
– Hardwire workflows
– Intelligent Decision Support
• Develop Community Resources
• Report on Success of Intervention
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The Ochsner Opioid Stewardship Team
Team Lead
Strategic Program
Manager
Opioid Stewardship Committee
Hospital Opioid
Stewardship
Clinic Opioid
Stewardship
ED Opioid
Stewardship
Pain Treatments
Urgent Care Opioid
Stewardship
Dependency Treatment
and Recovery
Opioid Diversion
Service Line Opioid
Management
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Patient and Provider Education
10
First Blinded data, then remove the blindfolds
40% decline in opioid rxs
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MEQ/Rx and % following guideline (3d/rx)
ED Alignment To Guidelines
12
Initial Resistance: HCAHPS
Physicians Who Prescribe Less Have
Same Patient Experience
70
75
80
85
90
95
100
0% 5% 10% 15% 20% 25% 30% 35% 40%
Patient Experience Mean Score
Opioid Prescribing Rate
Opioid Prescribing Rate vs. Press Ganey Mean Score by Physician
To Ease Fears, Removed Patient Satisfaction for Pain Despite
Lack of Correlation
13
Expand the Pilot – Inpatient OB discharges
Hardwire into D/C Ordersets
OB Adherence to Guideline (3d/rx)
14
Not just less prescribing, better prescribing
• Identify low risk vs high risk patients
• What did literature say
• Design best way to monitor patients getting opioids
– Minimize risk
– Monitor for misuse
– Communicate expectations with patients
• Hardwire best practices into workflow
• Monitor results and provide feedback
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Can we identify who is at risk for misuse?
• Opioid Risk Tool Questionnaire – University of Utah
– 5.6% of low risk patients developed misuse of opioid
– 90.9% of high risk patients developed misuse of opioids
– Coefficient 0.82 for males, 0.85 for females
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Custom Built Opioid Management Activity in Epic
Minimize End User Data
Entry
Auto Flags based on
Problem List
Auto Flags based on
Family Hx
Auto Flags based on
Social Hx
Differentiates between
validated and non-
validated scores
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Opioid Risk Tool Report and Explanation
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Opioid Management Tool - Resources
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Direct Links to Patient Assessment
PEG 3 and PHQ 4
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Tracking over Time
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Displaying the Score to End User
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How strong is that prescription?
• Concept of Morphine Equivalents Daily
Dose (MEDD)
• Issues of prn sig on prescriptions
• Complexities of Methadone in MEDD
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Best Practice of Care Based on Risk
• Separating acute from chronic users
• Minimizing Risk
– Naloxone Prescription
– Opioid Risk Tool Evaluation
• Monitoring Compliance
– Urine Drug Screens
• Communicating Expectations with Patients
– Pain Contracts
• Using tools End Users Familiar With – Health Maintenance
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Separating Acute from Chronic Users
• Rule based on 3 active rx for opioid in last 4 months
• Age > 18 (had age limit of 80 but removed this later)
• Not on hospice care
• No active diagnosis of cancer
• Inclusion rule added patients to registry based on risks
– Low risk – ORT score low, no hx of substance abuse,
MEDD<90, no concomitant benzodiazepine use
– Med risk – ORT score medium, no hx of substance abuse,
MEDD<90, no concomitant benzodiazepine use
– High risk – ORT score high, or hx of substance abuse or
MEDD>=90 or concomitant benzodiazepine use
• Vetted results with sample end users to confirm accuracy
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• Send to: All patients receiving
opioids for 3 of the last 4 months
– Once we figure out the roll out
date we can back into this
• Send to: All patients receiving
opioids from a provider who no
longer works for us
– Ongoing basis
• Delivery Mechanism: Mail to
patients directly
– Each Primary Care location
print the letter on their
letterhead so their patients have
the clinic number readily
available at the top of the letter
• Education: Notify Providers at
Primary Care Council meeting (prior
to letter “going live”)
• Tracking: Track letter delivery/sent
through MyChart and Letters Tab
Patient Letter
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Breakdown of Chronic Opioid Users
5724
506
1832
8062
5272
473
1771
7516
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
Low Risk Med Risk High Risk Total
Chronic Opioid Use Patients
Jun-18 19-Jan
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Breakdown of Chronic Opioid Use by Age
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
18-30 31-40 41-50 51-60 61-70 71-80 >80
Jun-18 Jan-19
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Various Diagnosis among Chronic Opioid Users
26.80%
35.60%
2.80%
1.90%
3.40%
0.70%
2.10%
22.40%
10.60%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
72% had some pain disorder on Problem List
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Narcotic Prescribed and Benzodiazepine Use
0%
10%
20%
30%
40%
50%
60%
70%
% Patients on Rx in last 6 months
"June 18"
"Jan 19"
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Health Maintenance Topic Rules
• Low Risk
– ORT completed
– Pain Contract signed
• Medium Risk
– Same as low
– UDS yearly
• High Risk
– Same as low
– UDS every 6 months
– Naloxone rx yearly
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Building Out Health Maintenance Rules
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Build HM into HM Overdue SmartSet
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Integrating Pain Contract Documents
• Created document type of pain contract for scanned documents
• Fax form with standard contract available via one click link
• Trained staff and HIM to scan documents into media tab
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Monitor for Misuse with PMP Link
• Identify vendor for HIE – Appriss
• Develop call out protocol and matching criteria
• Mark in Employee record who has PMP access
• One click solution
Information Technology Academy Journal 4/18
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In application PMP report viewing
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Innovative Approaches to Pain
Treatment
• Healthy Back Program
– 10 Week Program- Two Times
Per Week
– Patients Reported a 62.5%
Decrease in Pain After 10
Weeks of Treatment
• Medicaid Grants to Provide
Services Not Usually Covered:
• PT
• Paravertebral Facet Joint
Blocks
• Virtual Reality to Reduce Initial
Exposure to Opioids
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Functional Restoration Program
• Outpatient, Multidisciplinary,
Three-Week Program Includes:
– Pain Medicine, Pain Psychiatry
Specialists, Physical & Occupational
Therapists, Social Workers & Nutrition
Coaches
• Focus on Reclaiming Function &
Patient-Centered Goals
• Program Currently Completing
6
th
Cohort, 30-days After
Program, Patients Report:
– 51% Decrease in Disability Due to Pain
– 32% Improvement in Sleep
– 63% Improvement in Mood
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Opioid Free Cases
• Opiate Free Protocol
– Cases > 2 Hours
– Pre-operative IV
Acetaminophen and IV
Ibuprofen
• Started with Colorectal &
Urology Procedures
• Other Procedures to Limit
Opioid Use: Knee & Hip
Replacements
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Expanding Opioid Use Disorder Treatment
Options
• Our New Psychiatric Hospital- River Place Behavioral
Health- Will Open a Dual Diagnosis Unit in 2018
– Offering Detoxification and Induction with Buprenorphine
for Opioid Dependent Patients with Acute Psychiatric
Issues
• Psychiatry's Suboxone Program (OchMAT) is Underway
– Adding Additional Support to Capture a Greater Range of
Disease Severity.
• Intensive Outpatient Program for Substance Use
(Addictive Behavior Unit) is Streamlining its Services for
Opioid Dependent patients
– Providing Easier Access to Outpatient Suboxone
Treatment.
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Outcomes
• Prescription rates
• Guideline Compliance
• PMP registration
• Best Practice – Health maintenance
– ORT
– Pain Contracts
– UDS
– Naloxone Rx
• Expansion
– Concomitant benzodiazepine usage
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ED Prescription Data
(Began at 105 MEQ/rx and 50% guideline alignment (3d/rx))
% Alignment to Guideline
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OB Prescription Data
Alignment to Guideline (3d/rx)
% Alignment to Guideline
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Urgent Care Prescription Data
Alignment to Guideline (3d/rx)
% Alignment to Guideline
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System Wide Prescription Data
% Patients Seen in Office/ED/Hosp given Opioid
20,400 fewer patients on Opioids
ED Reporting
HM Go live
MEDD Go live
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System Wide Prescription Office Visit
Only
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System Wide Prescription ED Only
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PMP: Provider Registration 2018
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Jan Feb March April May June July Aug Sep Oct Nov Dec
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Health Maintenance Outcomes – Low Risk
24.0%
21.1%
14.0%
29.9%
26.5%
16.7%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
ORT completed Pain contract Both done
18-Jun 19-Jan
49
Health Maintenance Outcomes – Med Risk
64.0%
36.6%
31.0%
18.2%
73.9%
43.9%
39.6%
23.9%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
ORT completed Pain contract Urine Screen All 3
18-Jun 19-Jan
50
Health Maintenance Outcomes – High Risk
35.1%
24.6%
17.1%
15.3%
4.8%
45.8%
33.4%
21.6%
15.9%
4.5%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
18-Jun 19-Jan
51
Patients Getting Urine Drug Screening
33% increase
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Patients with Rx for Naloxone
96% increase
